L 5986 and Humana Advantage and commercial policy holders

L 5986 and Humana Advantage and commercial policy holders

Jim DeWees

8/23/2012

Hello Everyone (again), This is my Issue of the Day: Without getting into a long drawn out email, I wanted to send out an alert about L5986. I was on the phone yesterday, trying to get a pre-authorization for a BK prosthetic leg for a Medicare (Dis)Advantage plan member. Of course they claim they follow CMS Guidelines, and yet she was not able to tell me WHAT exact information they need from me to get the pre-auth. She said it was whatever CMS mandates, and I said that would mean NOTHING since CMS has never required pre-auths for any prosthetic devices. Upon further discussion, she said that there is NO way that I can be paid for L5986 anyway, since that is a RENTAL ITEM and not a PURCHASE item. I laughed at that, and asked her is she was kidding me, or serious. I made her read me that description of the code, and she had to dig that up, and I told her I would gladly wait, I have nothing better to do. After a couple minutes she gave up, and so I told her to just google that code, and she would find it...and so I read the description to her, and then asked HOW this could be a rental item. Anyway, the conversation didn't solve anything, except open her eyes at how stupid their policies are. I also contacted the assistant Director of Provider Relations, which was no easy task finding out who that was, but I have the OLD number of the former director, and left a voice message at his extension (which is someone else now, who is NOT in that department even), and I just went up the numbers calling every number starting with the ....0501, and then 0502, 0503, and did that about 6 times, and left messages on all these extensions for someone to contact me.

I DID get a call back, of course it was after 5:00, BUT I was prepared and had the phones transferred to my cell. Then she had to do some research. And then at 6:20 pm last night she called to leave a message for me, but unfortunately for her, I still had my phones transferred and talked to her again. She did see that the L5986 has been a rental item for a while now, and they did make that change yesterday to make it a PURCHASE item now. The assistant director assured me that they did change this code to a purchase item that quickly yesterday! All it took was someone going in and modifying their computer system, it is just a little code in THEIR system that denotes this item as rental or purchase...it's that simple I guess.
SO...PLEASE READ THIS PART IF NOTHING ELSE... Look at any of your charts that you billed for this code for all of your Humana patients, and see IF they paid for the L5986 codes or IF they put some kind of explanation where they did NOT pay for this code. ALSO it would be wise to check ALL of the codes and see if any others are not being paid due to them being listed as RENTALS. PLEASE let me know TODAY if possible if you can find any other codes. I am having a conference call with the director of Provider Relations today, with a few others at Humana to discuss how they are considering that they follow CMS protocol, when they are NOT doing that. Let me know if there are OTHER codes that are wrongly listed at rentals, or not being paid. I want to know these codes and I am sure that they will FIX these today after we speak about this issue. I am already in the process of another complaint with the OIG regarding how Humana appears to either be totally clueless, or totally incompenent with O&P coding, OR they are intentionally making it impossible to bill them correctly. If you have any patient charts where Humana has NOT paid, let me know and I will have an answer for you on how to re-bill Humana to have the claim adjusted and fixed. They know there are MANY claims that have been processed with this being a rental item. I could go on for a LONG time about had frustrating this issue is, and basically if we have billed them for this code, as a Purchase item, then WE are guilty of FRAUD since we are not abiding by THEIR billing rules. Another example of how these CMS issues are making more problems for all of us. Take care, I hope I just made a lot of you some additional money today with these billing problems....or at least a few of you can get paid and make Humana pay out as they should. Thanks Jim DeWees, CP
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